Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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Whether doing prehab, rehab or training, I believe in using single leg exercises to attack asymmetries, imbalances and motor deficits I uncover in my assessments. Learning to control one’s body in space with the effect of gravity in a weight bearing position is instrumental for sport and injury prevention.
Furthermore, facilitating ankle mobility and proper knee alignment during a loaded squat pattern is something most athletes and clientele I work with need some help with. to that end, I utilize several different single leg reaching progressions and exercises. One of my favorite ‘go to’ exercises is the anterior cone reach.
I recently featured this specific exercise in my ‘Functionally Fit’ column for PFP Magazine. Click here to see the video demonstration.
This is a great exercise with progressions and regressions for clients of all ages and abilities.
So, I just returned from the Combined Sections Meeting for the APTA that was held in Indianapolis. There was lots of great networking and presentations to be sure. I attended sessions on ACL rehab/prevention, femoroacetabular impingement, elbow injuries in throwers, running gait analysis, and shoulder plyometric training with the legendary George Davies. I thought I would give you my top 10 list of helpful nuggets I picked up over the weekend in no particular order of importance.
1. Performing upper body plyometrics has no effect on untrained subjects so don’t waste time putting it into the rehab program, where as it does benefit trained overhead athletes. The one caveat is it also increases passive horizontal external rotation so keep this in mind when working with athletes who have shoulder instability.
2. A new study coming out in 2015 in AJSM revealed no major differences in throwing kinematics between those following UCL reconstruction (Tommy John) and age-matched controls. This is good news for those worried about pitching mechanics after the procedure.
3. According to Dr. Reiman at Duke, the orthopedic hip exam does a better job of telling us they do not have a labral tear than it does telling us they do have an intra-articular problem. The tests have poor specificity. In fact, he goes on to say that the “special tests are not that special.” That brought a chuckle from the crowd including me. Bottom line – we are not really able to conclusively say “yes you have a labral tear based on my exam today.
4. Reiman also feels we must consider look for mechanical symptoms during the lowering portion of the Thomas test, while considering the fact that fat pad impingement may cause anterior hip pain as opposed to joint pain. Again, things are not always as they appear in the “FAI” crowd so we need to take a great history, look at the classic tests and also see how squatting and loading affects the hip.
5. More experienced pitchers do not drop the glove side arm, but instead tend to move their body toward the glove to conserve angular momentum and overcome small moments of inertia. Less experienced pitchers rotate their trunk sooner in pitching cycles whereas pitchers who threw at higher levels rotated later and produced less torque at the shoulder. Consequently, many players with higher elbow valgus torque and distraction force at the shoulder rotate too early.
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Every month there are new papers on ACL surgery and rehab appearing in the literature. I do my best to stay up on them as this is one area of my practice I am extremely passionate about. I am driven to understand as much as I can about both prevention and rehab, but find myself increasingly focused on preventing secondary ACL tears in my patients.
I feel poor movement patterns, muscle imbalances and inefficient neuromuscular control are major risk factors for athletes suffering a primary ACL tear. We also know being female markedly increases injury risk. Research also tells us that males are more likely to suffer a re-tear of the same side, whereas females are more likely to suffer a contralateral injury.
A study just published in the July issue of the American Journal of Sports Medicine looked at the incidence of second ACL injuries 2 years after a primary ACL reconstruction and return to sport. In a nutshell, the findings were:
- 24 months after ACLR and return to sport, patients are at greater risk (6x) to suffer a subsequent ACL tear compared to young athletes w/o a history of ACL injury
- Female athletes in the ACLR group are 5x more likely to suffer a second injury
- The contralateral limb of female athletes is at greatest risk
Click here to read the full abstract
This information is not surprising as I have seen it firsthand in 17 years as a physical therapist. What we do not have much information about is how do the younger patients (e.g 15 and under) really recover from this injury. When should they be cleared? I worked with a young female soccer athlete who tore her ACL and medial meniscus at age 13. She worked diligently with me in rehab 3x/week for about 6 months and then continued training with me at least 2x/week until she was about 1 year out from surgery.
Many athletes and clients struggle with hamstring muscle activation. A normal quad to hamstring ratio would be 3:2, but studies often find that subjects tend to be closer to 2:1 (especially females). This diminished ratio can increase knee injury risk (non-contact ACL) with jumping and cutting sports. Some people struggle with proximal hamstring tendinopathy related to overuse. Incorporating eccentric hamstring exercises in your training can markedly improve hamstring strength and activation patterns.
Quad/Ham dynamic relationship
Execution: Begin in supine with 90 degrees of knee flexion and the feet flat on the floor. Next, bridge up into a table top position. Then, slowly begin to walk the feet out keeping the weight on the heels in an alternating pattern. Move the feet as far away from the body as possible while maintaining a good static bridge position.
Once form starts to falter or fatigue sets in, walk the feet back in using the same cadence and incremental steps until the start position is achieved. Perform 5 repetitions and repeat 2-3 times. Focus on control while avoiding pelvic rotation, and be cautious working into too much knee extension to avoid poor form or cramping.
This is an excellent way to improve hamstring strength while emphasizing pelvic stability. This exercise should be preceded by static bridging to ensure the client understands how to maintain a neutral pelvic position (consider using a half roll or towel as a visual aid to cue him/her out of rotational movement initially). The walk out exercise can be implemented as part of ACL prevention/rehab programs and also works well for runners and athletes struggling with hip/pelvic stability, proximal tendinopathy and general posterior chain weakness.
Regression: Bridge up and march in place for repetitions or time to develop sufficient strength and stability.
Progression: Increase repetitions or slow the cadence down pausing longer at each step to increase time under tension. Additionally, move the hands from palm down to palm up to reduce stability. For advanced clientele, the arms could be crossed with the hands resting on the opposite shoulder.
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